Medication used in musculoskeletal conditions

Although some medications may be acceptable while flying or controlling, the underlying medical condition may be disqualifying. Aeromedical advice must be sought following a new diagnosis or recurrence/flare up of a medical condition.

Analgesics

Paracetamol (Acetaminophen) is similar in analgesic efficacy to Aspirin but has no anti-inflammatory activity. It has less irritant effect on the stomach and is preferable to non-steroidal anti-inflammatory drugs (NSAID's) for relief of mild to moderate pain. Paracetamol is acceptable for pilots provided the underlying reason for requiring pain relief has been considered and is compatible with flying.
Analgesic opiate medications such as Codeine and Dihydrocodeine, are incompatible with flying. While using this type of medication the pilot will be assessed unfit and the medical certificate will be temporarily suspended.

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) in single doses, have similar analgesic activity to Paracetamol. When used regularly they also have an anti-inflammatory effect. Pilots may fly unrestricted while taking NSAIDs provided the condition for which they are being taken is adequately controlled without side effects. Proton pump inhibitors can be used to control dyspepsia and for prevention of peptic ulceration in licence holders requiring long term NSAIDs.

Selective cyclo-oxygenase-2 inhibitors (e.g. Celecoxib, Etoricoxib) are licensed for the relief of pain in osteoarthritis, rheumatoid arthritis and ankylosing spondylitis. Etoricoxib is also licensed for use in gout. These medications are as effective in relieving pain as non-selective NSAIDs such as Diclofenac and Naproxen with less risk of upper gastrointestinal bleeding. These medications are acceptable for flying with the proviso that the degree of underlying pain and mobility should be assessed prior to, and be satisfactory for, certification.

Other medication

Glucosamine is licensed for mild to moderate osteoarthritis of the knee. It is acceptable for aviators to use although there is limited evidence of its effectiveness.

Corticosteroids (Prednisolone, Beclomethasone, Budesonide and Hydrocortisone)

Local corticosteroid injections may be given intra-articularly in inflammatory joint disease and directly into the soft tissues in conditions such as tennis or golfer’s elbow or compression neuropathies. Flying can be resumed a minimum of 48 hours after the injection provided the condition being treated is adequately controlled. Clinical examination by an AME may be required to assess range of movement, strength and dexterity.

Corticosteroids administered orally or rectally, can be effective in the treatment of active inflammatory disease. The use of oral steroids is disqualifying therefore, while using this type of medication, the pilot will be assessed unfit and the medical certificate will be temporarily suspended. (Note: certification may in exceptional cases be considered where no more than 7.5mg Prednisolone daily has been prescribed to reduce the rate of joint destruction in rheumatoid arthritis; such cases should be assessed in consultation with the AMS). Recertification can be considered when the certificate holder has been off oral steroid therapy for a minimum of two weeks with no recurrence of symptoms and the condition is confirmed quiescent.

Aminosalicylates, Medications Affecting the Immune Response, and Cytokine Modulators

The certificate holder is unfit on each occasion that a ‘flare up’ of the condition occurs and must seek aeromedical advice following any change in clinical condition, or medication.

• Aminosalicylates (Mesalazine, Balsalazide and Olsalazine)
• Medication affecting the immune response (Ciclosporin, Mercaptopurine, Azathioprine and Methotrexate)
• Cytokine Modulators (Adalimumab, Etanercept and Infliximab)*

If indicated for the treatment of active inflammatory disease these medications are disqualifying. These medications may be acceptable for maintaining remission of the disease provided the disease is quiescent, the certificate holder does not experience side-effects and regular review is undertaken.

There is additional guidance for hydroxychloroquine.